reproductive health focus report on projects for reduction of material anemia

53 Pages·2000·1.49 MB·English

REPRODUCTIVE HEALTH FOCUS
REPORT ON PROJECTS FOR REDUCTION OF MATERIAL ANEMIA
John Snow, Inc.
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those of the author(s) and do not necessarily reflect the views of the U.S. Agency for
International Development or John Snow, Inc.
Vadodara, India: The Impact of Iron Supplements
on Adolescent Growth and Anemia Prevalence
Investigators: Shubhada Kanani1
Rashmi Poojara1
Vaishali Zararia2
Minaxi Mistry2
Collaborating Agencies: 1Department of Foods and Nutrition, M.S. University of
Baroda
2Baroda Citizens Council
Project Period: 1997 - 1998
I. Background:
Adolescence is second only to infancy as the period of most rapid growth. Adolescents
are also particularly vulnerable to both macro and micronutrient deficiencies. Globally,
26% of adolescents in developing countries are anemic, but recent studies conducted by
the Department of Food and Nutrition, M.S. University of Baroda found anemia (Hb <
12g/dL) prevalences to be above 70% among adolescent girls in Vadodara. Because
maternal anemia is linked with a high risk of maternal and fetal deaths, premature
delivery, low birth weight, and perinatal mortality (WHO 1986), programs aimed at
improving the health and nutritional status of adolescent girls are necessary so that girls
enter their reproductive years without serious iron deficiency. There is also a need to
impart nutrition education to adolescent girls in an effort to increase their intake of iron
rich foods.
Earlier qualitative studies (Kanani, 1994) show that adolescent girls experience a range of
symptoms associated with anemia and some have ideas about interventions to cure the
condition (e.g., improved dietary quality and “tonics”). Anorexia (loss of appetite) is one
of the symptoms associated with anemia. This is of particular concern for adolescents as
it may adversely affect dietary intake and growth.
Over the past decade, India has seen a steady increase in the enrollment rates of girls
within the school system (UNICEF 1994). This phenomenon, combined with
unacceptably high anemia prevalence rates among this vulnerable group led the
researchers to investigate the impact of iron supplementation on poor urban adolescent
girls, using the school system as a vehicle for anemia reduction with a weekly IFA
intervention. A second study, community-based, with urban poor girls, pursued anemia
reduction through a daily IFA intervention.
II. Study Objectives and Strategies:
A. Daily Iron Supplementation
1. Objective
To assess the impact on growth, hemoglobin status, and appetite of daily iron folate
supplementation tablets over a 3-month period on urban slum-dwelling adolescent girls.
2. Study Population and Methods
This study was carried out in three slums of Vadodara, where the Baroda Citizens Council
(BCC) implements community development programs. Of the 203 study participants, whose
ages ranged from 10 to 18 years, 56% of the girls were Hindu. Approximately 50% of the
family per capita incomes ranged from $5-10 per month. Anemia prevalence (Hb <12g/dL)
was 81% among the study population. Any girls with severe anemia (defined as Hb <8 g/dL
in this study) were excluded from the study (although no such girls were identified). More
than half (59%) of the girls were undernourished (body mass index < 80% of the standard).
Approximately 20% of the girls consumed meat or eggs weekly, while 33% consumed meat
or eggs once in a two-week period. Anemic subjects scored significantly lower on a rating
scale for measuring appetite than non-anemic subjects in the baseline assessment.
Two of three slums were randomly allocated to either the control group, and the third was the
experimental group. Girls received either one tablet containing 60 mg elemental iron and 0.5
mg folic acid or a placebo tablet (dicalcium phosphate) daily for three months. Baseline
assessments included biochemical and anthropometric measurements (hemoglobin, weight
and height-for-age, BMI), dietary intake by food frequency questionnaires, history of anorexia
(checklist and rating scale) and perceptions of health, nutrition, and anemia using a semi-
structured questionnaire. Masters and doctoral students from the Department of Foods and
Nutrition, M.S.University of Baroda, functioned as data collectors and were involved in the
data management, analysis, and report production.
3. Results
A high level of compliance with the iron supplements was achieved with 90% of the
participants consuming more than 85 of the 90 tablets. Girls in the experimental group
experienced a significant (p<0.001) mean change in hemoglobin level (+1.73 g/dL) compared
to the girls in the control group (-0.08 g/dL). The increment of change was more pronounced
in the anemic subjects. There was a marked shift to the right in the hemoglobin frequency
distribution curve of the experimental group after the intervention that was not reflected in the
control group. Appetite scores significantly (p<0.001) improved among the girls in the iron
supplementation group, according to the checklist and self-rating. Iron supplementation
appeared to maintain BMI in the experimental group, while there was some deterioration in
BMI among the control group; the trend was similar when the results were disaggregated by
anemia status. Weight gain was significantly (p<0.001) greater (close to 1 kg) among the
supplemented girls; the increase was negligible among the control group (.04 kg).
Disaggregation by anemia status did not produce the anticipated difference in weight gain.
B. Weekly Iron Supplementation
1. Objective
To assess whether weekly supplementation with iron folate tablets provided through schools
for a 6 month period has an impact on increasing appetite, growth, and hemoglobin levels of
adolescent girls.
2. Study Population and Methods
The study population was drawn from a school in urban Vadodara serving girls from low to
middle income households. The entire school population was sampled, yielding an initial
sample size of 2090 girls. Monthly per capita income of 50% of the families was
approximately $5-14. Ninety-five percent (95%) of the girls were vegetarian, and 99% were
Hindu. According to BMI at baseline, 25% of the participants were undernourished (below
80% of reference standard BMI). Overall, 75% of the girls had anemia (Hb <12g/dL), and 7%
had severe anemia (Hb <8.0 g/dL). Girls with severe anemia were treated and excluded from
the study. Dietary consumption of iron-rich or iron absorption enhancing foods was low due
to a combination of vegetarian diet restrictions (no animal products) and dislike of alternative
sources of iron. No difference in mean appetite scores was found between anemic and non-
anemic subjects at baseline. This was attributed to the difficulties of administering the
assessment tool to a large sample of girls (n=1013); individual assistance and supervision was
not possible as in the first study.
The study design was a double blind experimental placebo controlled trial. A total of 1517
girls were stratified by age into 3 groups (10 to 12 years, 13 to 15 years, and 15 to 19 years).
They were further divided by hemoglobin levels (> 11g/dL, 8.1 to 10.9 g/dL, < 8g/dL) and
girls in the first two hemoglobin groups were randomly assigned to experimental or control
groups. The experimental participants were given weekly iron folate supplements containing
100 mg elemental iron and 0.5 mg folic acid. The control group was given weekly dicalcium
phosphate placebo tablets.
Supplementation was supervised in the classroom for 6 months. Classroom teachers and
study investigators monitored compliance with supplement consumption and recorded
compliance in specially designed registers.
3. Results
Impact analysis was performed for the 729 girls who consumed at least 80% of the total dose
of tablets (21 or greater). There was no significant difference in the extent of decrease in
percent prevalence of anemia between the experimental and control groups. There was a
similar shift to the right in the frequency distribution curve of both groups indicating that
improvements in hemoglobin status are more a function of adolescent growth than the impact
of weekly iron folate supplements. Similar increases in growth – weight, height, and BMI –
were noted in both experimental and control groups, whether grouped overall, or
disaggregated by anemia status.
Teaching staff was highly cooperative with the administration of tablets and compliance
monitoring. In the few situations where teachers were unhappy about the time costs, students
enthusiastically assumed responsibility for tablet distribution and compliance monitoring. The
age of the girls affected compliance; younger girls were more compliant than their older
counterparts.
III. Project Outcome:
Daily iron folate supplements for 3 months produced positive impacts on adolescent girls’
hematinic status and growth, in contrast to an absence of significant impact among girls
supplemented weekly for a period of 6 months. A non-significant trend toward improvement
in hemoglobin level was evident among the experimental group in the weekly trial, but among
this study population of rapidly growing anemic girls, the weekly supplementation regimen
was not adequate to meet iron needs, significantly reduce anemia, or improve growth.
IV. Key Conclusions Regarding Lessons Learned:
Raising the iron status of adolescent girls is important for their own health and well-being
as well as for their long-term reproductive health.
Few studies have looked at the impact of iron/folate supplementation on adolescent
growth. The results of the first study indicate that among some populations, daily iron
supplementation for at least 12 weeks can improve pubertal growth, possibly through
improved appetite.
While there have been several studies in different regions of the world that document
efficacy of a weekly iron/folate regimen among non-pregnant women and adolescents,
the second study in Vadodara did not demonstrate similar results. Apparently the iron
needs of this population of rapidly growing, anemic adolescents exceeded the amount of
iron available in a weekly dose.
Both studies suggest that with well designed nutrition awareness activities combined with
counseling on management of side effects, a majority of adolescent girls will comply
with either daily or weekly IFA supplements. Implementing these interventions through
the schools appears to be a feasible method for reaching large numbers of girls during
their pre-adolescent and adolescent years (at least in settings where many, if not most
girls attend secondary school). In the adolescent span of 10 through 19 years of age, the
younger girls (10-14 years old) especially the pre-menarcheal phase, should be the focus
of attention for improving growth and reducing anemia as they are undergoing rapid
pubertal growth and tend to be more undernourished than older girls.
V. Publications:
• Shubhada, Kanani; Poojara, Rashmi. Supplementation with Iron and Folic Acid
Enhances Growth in Adolescent Indian Girls. Journal of Nutrition. 130: 452S-455S,
2000.
• Shubhada, Kanani; Poojara, Rashmi. Supplementation with Iron and Folic Acid
Enhances Growth in Adolescent Indian Girls. Experimental Biology Symposium:
Improving Adolescent Iron Status before Childbearing, Washington, DC. April 17-
21, 1999.
• Shubhada Kanani et al. The Impact of Iron Supplementation on Appetite and Growth
of Adolescent Girls of Vadodara. Vadodara, India: John Snow, Inc., MotherCare,
1998.
Vadodara, India: Health Systems Research for
Anemia Control and Pregnancy
Investigators: Shubhada Kanani1
Jai Ghanekar1
Smita Maniar2
Collaborating Agencies: 1Department of Foods and Nutrition, M.S. University of
Baroda
2Baroda Citizens Council
Vadodara Municipal Corporation Health Department
Project Period: January 1997-August 1998
I. Background:
In the urban slums of Vadodara, India low compliance with iron folic acid (IFA) tablet
supplementation by pregnant women is in part due to shortcomings in the delivery system
and ineffective promotion strategies. In 1990 only 25% of pregnant and lactating women
from the slums had received a full course of iron supplements and 33% had not received
supplements at all (Nutrition Research and Training Centre 1990). The IFA tablet
delivery system of the anemia control programs in the Vadodara Corporation was found
to be unsatisfactory: the system was lacking in structure and had no designated days for
tablet distribution, no tracking system in place to record the number of tablets distributed
or consumed, and client follow-up and counseling were inadequate.
In Vadodara, the iron supplementation delivery system is managed through the Family
Centres and Health Posts of the Vadodara Municipal Corporation (VMC). Each of the
nine health posts covers a population of approximately 50,000, and is staffed by one Lady
Medical Officer (LMO), one Female Supervisor (FHS), four Female Health Workers
(FHWs), one vaccinator, an accountant clerk, and one assistant. The Anemia Control
Program (ACP) implemented through the health posts and home visits is similar to
India’s national program, with 100mg elemental iron + 0.5mg folic acid tablets given
daily to pregnant and lactating women for 100 days.
II. Study Objectives:
The major objective was to improve the implementation of antenatal care (ANC)
services, with special emphasis on anemia control, in two Health Posts of the Vadodara
Municipal Corporation serving lower socioeconomic urban areas with a population of
approximately one million. The following is a list of specific objectives:
1. To conduct a situational analysis of the Anemia Control Program for urban, poor
pregnant women.
2. To improve the implementation of the antenatal care services, especially anemia
control in pregnant women, by the health functionaries (Lady Medical Officer,
Female Health Worker).
3. To evaluate the effectiveness of different program strategies for improving
antenatal care and anemia control such as training, procurement and distribution of
iron tablets, production of IEC materials and its use by FHWs, monitoring, and the
supervisory system.
4. To assess the impact of enhanced antenatal care and anemia control on anemia,
beliefs and practices regarding anemia and iron supplementation among pregnant
women, and on the birthweight of newborns.
III. Study Strategies:
The study to improve the delivery system of IFA tablets was divided into four phases: 1)
Phase I - A situational analysis in which formative research was carried out with
functionaries of all 9 health posts of the Corporation; 2) Phase II- The development and
implementation of selected strategies with participation of VMC’s health officials; 3)
Phase III - An iterative process alternating process evaluation and program improvement
focused on changes occurring in the health system; and 4) Phase IV - Advocacy efforts
undertaken with the Government of Gujarat health officials to emphasize the need for
giving ACP much needed attention and to improve the quality of its implementation.
III. Results:
Phase I - The Anemia Control Program: Results of the Situational Analysis
1. Health workers
• The FHWs undergo training for 1½ years after secondary schooling. This training
includes a course on nutrition in which the FHWs receive information regarding vitamins
and minerals including iron.
• According to a nursing tutor, anemia control was a weak component of the training and
not much importance was given to it. There were few IEC materials on anemia and the
benefits of iron supplementation to be used in training as well as with the general public.
The chief medical officer and the FWMO who oversee the Corporation’s health program
stated that the Government of Gujarat (GOG) pays little attention to urban functionaries’
training needs; most of their training programs concentrate on rural programs.
• The supply of IFA tablets in the health centers was sometimes inadequate, erratic, and
their distribution by health functionaries’ was infrequent. Home visits by FHWs were
irregular and no follow up visits were made to monitor compliance. Monitoring was done
only with regard to the number of tablets given to pregnant women who visit the MCH
clinic.
• The health providers were well aware of the common causes of anemia. All health
workers (LMOs, FHSs, and FHWs) said that they counseled women to take IFA tablets
and to increase the intake of iron-rich foods. The general problem encountered during
counseling, according to them, was that though the women agreed to take iron tablets they
did not put the advice into practice. Health workers noted the main reasons behind non-
consumption of iron tablets to be the lack of awareness regarding the benefits of tablet
consumption, side effects, unpleasant taste, and refusal of the woman’s elder family
members allowing the woman to consume the tablets. It was suggested that the family
members of the women should be taken into confidence to gain their cooperation.
2. Pregnant Women
• Pregnant women residing in the areas of the health posts were enrolled in the study if they
were 20-24 weeks of gestation (n=153). They were classified, based on their hemoglobin
levels, into normal (Hb ‡ 11 g/dL), mildly anemic (Hb = 10-11 g/dL), moderately anemic
(Hb = 7-9 g/dL), and severely anemic (Hb < 7 g/dL). The anemia prevalence was 88% in
the group with 11% of women having severe anemia.
• When asked to free-list foodstuffs they thought would strengthen their blood, the women
showed lack of awareness regarding specific foods rich in iron and vitamin C. Food
intake data suggest that in view of the availability of iron and vitamin C rich foods, as well
as few food taboos during pregnancy, it is likely that a well implemented nutrition and
health education program would help encourage women to improve their diets.
• The majority of the women were registered in health facilities and their family members
were aware of it. The awareness of services such as weight monitoring, receiving iron
tablets, vaccination against tetanus toxoid, and physical checkups was found to be higher
(43-65%) compared with services such as receiving nutrition health education (NHE),
including dietary advice (2-3%).
• All ANC services were perceived to be useful by the women and their family members;
however, half of them could not elaborate on the reason. The awareness of the purpose of
NHE was low in the pregnant women and even lower in their family members. This may
be due to the fact that NHE is infrequently administered during ANC visits. More than
80% of the family members could not respond regarding NHE.
• Regarding the importance of iron supplementation to increase appetite, awareness was
higher in the pregnant women (60%) than their family members (35%). Pregnant women
were aware of the benefits of iron supplementation.
• Less than half of the women and family members gave suggestions regarding the
improvements of ANC services listed below:
1. Transportation available to and from the health post to the slum area for antenatal
check-up and to take the women to government hospitals at the time of delivery
2. Home visits by the doctors in the community
3. NHE to be given during the home visits by the FHWs and the doctors
4. Other medicines for common illnesses such as fever or cold should be provided at the
health posts